The Effectiveness of an Intensive Interdisciplinary Pain Rehabilitation Program in the Treatment of Post-Laminectomy Syndrome in Patients Who Have Failed Spinal Cord Stimulation

Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review

Amid the worldwide increase in spinal surgery rates, a significant proportion of patients continue to experience refractory chronic pain, resulting in reduced quality of life and escalated healthcare demands. Failed back surgery syndrome (FBSS) is a clinical condition characterized by persistent or recurrent pain after one or more spinal surgeries. The diverse characteristics and stigmatizing descriptions of FBSS necessitate a reevaluation of its nomenclature to reflect its complexity more accurately. Accurate identification of the cause of FBSS is hampered by the complex nature of the syndrome and limitations of current diagnostic labels. Management requires a multidisciplinary approach that may include pharmacological treatment, physical therapy, psychological support, and interventional procedures, emphasizing realistic goal-setting and patient education. Further research is needed to increase our understanding, improve diagnostic accuracy, and develop more effective management strategies.

Baseline Factors Associated with Pain Intensity, Pain Catastrophizing, and Pain Interference in Intensive Interdisciplinary Pain Treatment for Youth

Background: More could be known about baseline factors related to desirable Intensive Interdisciplinary Pain Treatment (IIPT) outcomes. This study examined how baseline characteristics (age, gender, child pain catastrophizing (PCS-C), pain interference, pain intensity, anxiety, depression, paediatric health-related quality of life (PedsQLTM), and parent catastrophizing (PCS-P)) were associated with discharge and 3-month follow-up scores of PCS-C, pain intensity, and pain interference. Methods: PCS-C, pain intensity, and pain interference T-scores were acquired in 45 IIPT patients aged 12-18 at intake (baseline), discharge, and 3-month follow-up. Using available and imputed data, linear mixed models were developed to explore associations between PCS-C, pain intensity, and pain interference aggregated scores at discharge and follow-up with baseline demographics and a priori selected baseline measures of pain, depression, anxiety, and PCS-C/P. Results: PCS-C and pain interference scores decreased over time compared to baseline. Pain intensity did not change significantly. Baseline PCS-C, pain interference, anxiety, depression, and PedsQLTM were associated with discharge/follow-up PCS-C (available and imputed data) and pain interference scores (available data). Only baseline pain intensity was significantly associated with itself at discharge/follow-up. Conclusions: Participants who completed the IIPT program presented with reduced PCS-C and pain interference over time. Interventions that target pre-treatment anxiety and depression may optimize IIPT outcomes.

Teleexercise for geriatric patients with failed back surgery syndrome

Introduction

Failed back surgery syndrome (FBSS) is defined as back pain which either persists after attempted surgical intervention or originates after a spine surgery. There is a high risk of perioperative morbidity and a high likelihood of extensive revision surgery in geriatric patients with FBSS or post-laminectomy foraminal stenosis.

Methods

There is a need for less invasive methodologies for the treatment of FBSS, such as patient-tailored exercise training, with attention to the cost and special needs of the geriatric patients with FBSS. This commentary will provide some background regarding teleexercise (utilizing an internet-based platform for the provision of exercise-related care) for FBSS and will propose three exercises which are easy to administer over online-based platforms and can be the subject of future investigation.

Results

Given the documented benefits of regular rehabilitative exercises for patients with FBSS, the high cost of face-to-face services, and the need for infection mitigation in the wake of the COVID-19 Pandemic, teleexercise may be a practical and cost-beneficial method of exercise delivery, especially for geriatric patients with limitations in mobility and access to care. It should be noted that, prescription of these exercises should be done after face-to-face evaluation by the physician and careful evaluation for any “red flag” symptoms.

Conclusion

In this commentary, we will suggest three practical exercise training methodologies and discuss the benefits of teleexercise for geriatric patients with FBSS. Future research should aim to assess the efficacy of these exercises, especially when administered through telehealth platforms.

Mediators of change in depressed mood following pain rehabilitation among participants with mild, moderate, or severe depressive symptoms

BACKGROUND

Prior research indicates that depression and chronic pain commonly co-exist and impact each other. Interdisciplinary pain rehabilitation programs (IPRPs) have been shown to lead to statistically and clinically significant improvements for patients who report both depressed mood and chronic pain, however there is a gap in the literature regarding the mechanisms by which these improvements occur.

METHODS

This two-site, distinct sample study (Study 1: N = 303, 10-week, individual format, ACT-based program; Study 2: N = 406, 3-week, group format, CBT-based program) evaluated mediators of treatment improvement in depressive symptoms among adult IPRP participants who reported elevated depressive symptoms at program admission and examined treatment mechanisms for depressive symptoms.

RESULTS

Self-reported pain self-efficacy and pain catastrophizing - particularly the helplessness domain - mediated the treatment-related change in depression among IPRP participants with elevated depressive symptoms across the two sites and samples. In one sample, full mediation was achieved while in the other sample, partial mediation was achieved. Participants in both samples showed improvement on all measures.

LIMITATIONS

This study relied on self-report measures of depressive severity and not clinical diagnosis. Results may not generalize to other populations of patients with chronic pain. There was no control condition in either study.

CONCLUSION

Increasing pain self-efficacy and decreasing a sense of helplessness are important treatment targets among IPRP participants who endorse symptoms of depression.

Lack of Neuromodulation Knowledge Among Rural Family Medicine Residents: A Call for Implementation Research

Objective

Spinal cord stimulation is a proven, evidence-based therapy for persistent spinal pain syndrome. While some patients with this disease are managed by chronic pain physicians, many are managed in primary care offices. Despite mounting evidence, dissemination of this research outside of neuromodulation related fields and implementation of this treatment in common practice has not yet occurred. We hypothesize that family medicine residents in rural training programs will have little knowledge of neuromodulation despite it being an evidence-based and common treatment of post-laminectomy syndrome.

Materials and Methods

Online surveys were sent to family medicine residents in six rural family medicine training programs at the University of Arkansas for Medical Sciences Regional Programs to characterize knowledge of neuromodulation as a treatment for post-laminectomy syndrome.

Results

Forty-one percent of responding rural, Arkansas family medicine residents reported treating post-laminectomy syndrome during their training, yet only 10% have referred a patient for neuromodulation consultation. Residents rated their knowledge of neuromodulation/spinal cord stimulation at 19 on a scale of 0 (no knowledge) to 100 (extensive knowledge).

Conclusion

Despite proof that neuromodulation is an evidence-based treatment for post-laminectomy/failed back syndrome, rural family medicine residents have limited knowledge about the therapy and many do not consider a referral for neuromodulation. Further research to ascertain effective implementation strategies to increase the uptake of neuromodulation for patients with post-laminectomy syndrome is desperately needed.

Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia

OBJECTIVE

To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida.

PATIENTS AND METHODS

A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group).

RESULTS

By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group.

CONCLUSION

Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.

Pain rehabilitation's dual power: Treatment for chronic pain and prevention of opioid-related risks

The purpose of this article is to provide a data-driven exploration of an interdisciplinary pain rehabilitation program (PRP) as a viable option for addressing the dual crises of chronic pain and opioid use. Psychologists are crucial providers in the PRP, in both intervention and leadership roles. There is well-established literature supporting pain rehabilitation as an effective treatment for chronic pain and functioning, but there are few studies examining the effects of pain rehabilitation on opioid misuse risk. We evaluated data from 60 patients with diverse chronic pain conditions who completed an interdisciplinary PRP to evaluate changes in pain, functioning (self-report and objective physical measure), psychological symptoms, and health-related quality of life. To evaluate the effect of pain rehabilitation on opioid-related risks, we examined opioid use and opioid misuse behaviors (measured by the Current Opioid Misuse Measure; COMM) pre- and posttreatment. Results demonstrated statistically significant improvements in all outcomes, with medium effect sizes for pain severity and large effect sizes for functioning, psychological symptoms, and emotional quality of life. Fifty-eight percent of patients were on opioid medications at entry compared with 15% at discharge. Among patients who entered on opioids, mean COMM scores were significantly reduced from above the cutoff for misuse risk (M = 13.57) to below the cutoff (M = 5.86). Overall, this study provided strong support for pain rehabilitation as an effective treatment for chronic pain and related suffering, while also providing a prevention-based opportunity for reducing opioid-related risk. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effectiveness of physiotherapy interventions on pain and quality of life in adults with persistent post-surgical pain compared to usual care: A systematic review

Background

Persistent post-surgical pain (PPSP) is a common condition following surgery, resulting in persistent pain and reduced quality of life (QoL). While pharmacological management is common, its effectiveness remains equivocal. This systematic review investigated the effectiveness of physiotherapy management in adults with PPSP in comparison to usual care.

Methods

A systematic search of six electronic databases was conducted. Studies of human adults (>18 years) with PPSP localised or directly referred from the surgical site, pain persisting for at least two months post-surgery and with physiotherapy as the intervention were included. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The McMaster critical review form for quantitative studies was utilised to assess the methodological quality. A descriptive synthesis was undertaken due to the heterogeneity of the included studies.

Results

Of the 1395 articles that were screened, eight studies met the inclusion criteria. A diverse range of physiotherapy interventions were utilised, and effectiveness was measured through diverse outcomes and measures. Summarised findings from the heterogenous evidence base indicated that physiotherapy interventions for PPSP has a positive impact across a range of outcomes, including pain, quality of life (QoL), physical function and depression. While these are encouraging findings, the current evidence base lacks uniformity with regards to participant characteristics, time periods since diagnosis, interventions delivered, and its parameters, and outcomes measured.

Conclusion

Due to ongoing challenges in the management of PPSP, alternate treatment strategies such as physiotherapy are being trialled. Despite a number of methodological constraints, current evidence indicates that physiotherapy could play a role in the management of PPSP.

PROSPERO registration

CRD42019129580

miR‑519d‑3p promotes TGFβ/Smad mediated postoperative epidural scar formation via suppression of BAMBI

To investigate the role of microRNA (miR)‑519d‑3p in postoperative epidural scar formation and its regulation of the bone morphogenetic protein and activin membrane‑bound inhibitor (BAMBI), miR‑519d‑3p and BAMBI expression levels in the lumbar disc of patients who had undergone laminectomy were detected with reverse transcription‑quantitative polymerase chain reaction and western blotting. The results demonstrated that miR‑519d‑3p expression was significantly increased, whereas BAMBI expression was sharply reduced in the lumbar discs of patients suffering from epidural scars. Subsequently, the miR‑519d‑3p mimic was transfected into primary fibroblasts isolated from epidural scar tissues. Flow cytometric and Cell Countin Kit‑8 analyses indicated that overexpression of miR‑519d‑3p promoted the proliferation of fibroblasts, the production of tumor necrosis factor‑α and interleukin (IL)‑1α, and the expression of type I collagen (col I), α‑smooth muscle actin (α‑SMA) and fibronectin (FN). Downregulation of miR‑519d‑3p by the miR‑519d‑3p antagomir transfection had the opposite effect. Bioinformatics and luciferase reporter gene analyses demonstrated that BAMBI is a target gene of miR‑519d‑3p: miR‑519d‑3p directly binds to the 3'‑untranslated region of BAMBI mRNA and suppressed BAMBI protein expression. Finally, the pcDNA‑BAMBI vector and BAMBI small interfering RNA were respectively transfected into primary fibroblasts to overexpress and knockdown the BAMBI gene. It was demonstrated that BAMBI overexpression suppressed fibroblast proliferation, TNF‑α and IL‑1α production, and the expression of col I, α‑SMA and FN proteins, whereas, BAMBI knockdown had the opposite effect. In conclusion, it was noted that BAMBI is a target of miR‑519d‑3p and miR‑519d‑3p promotes transforming growth factor β/mothers against decapentaplegic homolog 9‑mediated postoperative epidural scar formation via suppression of BAMBI.